ASSIGNMENT
Submitted by:
Fathima Shahanaz
[Link] DSD 2nd year PG
NEAR TOTAL LARYNGECTOMY
Introduction:
Near-Total laryngectomy is a procedure described by
Dr. Bruce Pearson from the Mayo Clinic way back in 1981.
Near total laryngectomy was described by Pearson as an alternative treatment for patients with T3 and T4
laryngeal carcinomas.
With this treatment, these patients would be spared a life without speech, which is the main consequence of
total laryngectomy. Initially described as "extended vertical hemilaryngectomy" or "subtotal laryngectomy,"
this technique was developed over time; "near-total laryngectomy with partial pharyngectomy" was
developed to include the base of the tongue and the hypopharynx, and "near-total laryngopharyngectomy"
was developed to take advantage of pedicled flap reconstruction.
The aphonic condition that the patient has to face after total laryngectomy has deep psychological and
debilitating effects on the human psyche. For this reason, extensive work has been carried out on alaryngeal
voice production since the beginning of the [Link] of adynamic tracheoesophageal shunt
methods have been described mainly as aspiration, stenosis, and difficulty with hygiene.
Near-total laryngectomy is a surgical treatment modality that was specially designed to overcome these
serious complications of adynamic tracheoesophageal shunt methods.
The subglottis is defined as the laryngeal subdivision bounded superiorly by the junction of squamous and
respiratory epithelium on the undersurface of the true vocal cords, which has been arbitrarily assigned to the
point 5 mm below the free edge of the true vocal [Link], it extends down to the inferior border of
cricoid cartilage.
Primary tumors originating from the subglottic region are rare. Tumors located in the subglottic region are
usually extensions from the glottic or even supraglottic region by paraglottic space involvement.
In their study to investigate the means of tumor spread, Strome et al determined that the fibroelastic barriers
located in the subglottic region are predisposed to cancerous invasion. According to the results of this study,
even the cartilaginous structures escape tumor invasion until the advanced stages, whereas the ability of
cancer to invade these fibroelastic barriers leads to insidious spread of the disease. Tumor progression
occurs mainly in the paraglottic region, and the potential for mucosal spread is limited. A normal endoscopic
appearance can be observed in such a patient because of the absence of mucosal spread as the disease
progresses to advanced stages.
Laryngeal carcinomas extending to the subglottic region or even to several rings of the upper trachea were
also covered by the classic indications for the operation when described by Pearson.
The procedure was a brilliant method to create a biological shunt between the airway and the neopharynx to
restore speech. Unlike other biological shunts, this was a dynamic myomucosal shunt. All it required was that
the disease in the laryngopharynx should be lateralized and it should be possible to save an innervated
cricoarytenoid unit with two thirds of the vocal cord. The NTL shunt is biological(utilising patients remnant
cricotracheal mucosa and true cord) and dynamic (prevents aspiration due the resting closed state of the
shunt opening). This was a real improvement over other biologic shunts.
INDICATIONS
The near-total laryngectomy is designed for advanced laryngopharyngeal cancers where the cord is fixed and
there is laryngeal framework involvement. The disease should be however lateralized and not involve the
central laryngeal framework. Thus, an advanced glottis cancer may destroy the thyroid cartilage but the
interarytenoid tissue should be free of disease. In an advanced supraglottic or hypopharyngeal cancer, the
disease should not enter the postcricoid mucosa.
Procedure:
In a patient satisfying the criteria of uninvolved interarytenoid and postcricoids mucosa, the larynx is opened
carefully taking care that whilst the tumor is removed with oncologic principles the uninvolved larynx, i.e. at
least two-third of the vocal cord, the cricoarytenoid unit and the contralateral recurrent laryngeal nerve
(RLN) is preserved.
Thus, all the steps are carried out with the objective of visualizing the interarytenoid and postcricoid mucosa
and preserving contralateral inferior cricothyroid joint and the RLN.
PREPARING THE CRICOTRACHEAL MUCOSA FOR THE SHUNT
● The specimen is removed and the preserved structures evaluated.
● The RLN, the arytenoid cartilage and the length of the true vocal cord are inspected.
● The true vocal cord should be adequate to form a shunt by suturing it to the interarytenoid region. If
this is short then augmentation of the mucosa is done with help of the pyriform sinus mucosa.
● The next step is to mobilize the cricotracheal mucosa to form the shunt. For this purpose, the
mucosa is elevated by subperichondrial dissection off the cricoid cartilage adequately and then
resecting the cricoid cartilage preserving the cricoarytenoid joint region.
● This allows the mucosa to be sutured to form the shunt.
NEAR-TOTAL SHUNT CREATION
● The 1st tracheal cartilage is divided in midline by excising a small wedge. This facilitates the
formation of the shunt.
● This is a modification from the original Pearson procedure.
● The shunt is now sutured over a red rubber catheter of 12Fr to ensure that 30 to 40 mm of H2O
pressure is generated to produce an intelligible and sufficiently loud speech.12 The catheter is
placed from the tracheostome to the interarytenoid region.
● The shunt suturing is done over this catheter.
● This ensures the shunt being of adequate diameter and prevents generous mucosal bites with the
needle whilst suturing which can lead to a narrow shunt and subsequent shunt stenosis.
● The shunt closure is done with simple interrupted sutures using absorbable material made from
polyglycolic acid . The mucosal edges are brought together carefully and at the level of the true
cords the thyroarytenoid muscle is sutured to the interarytenoid muscle.
● This creates a sphincter which remains closed during swallowing and opens only during phonation,
thus preventing aspiration. If the shunt is too wide at the level of the arytenoid, it can result in
aspiration.
While creating the shunt ensure that:
1. The cricotracheal mucosa has no lacerations.
2. The edges are clean
3. The suturing is done over a catheter to create an adequate diameter shunt
NEOPHARYNX
● After the shunt is created, the neopharynx is formed by suturing the edges of the remnant
pharyngeal mucosa. The pharyngeal mucosa is measured and only if it is adequate, i.e. more than 3
cm of unstretched mucosa then a primary closure of the pharynx undertaken.
● Augmentation of the pharyngeal remnant can be done with pectoralis major myocutaneous flap
(PMMC) or a free forearm radial artery based fasciocutaneous flap.
● Augmenting the pharynx bears no relation on the outcome of the voicing. The shunt is independent
of the neopharynx.
Oral Intake and Voicing
● The near-total laryngectomy has a potential for leak due to the invagination of the shunt into the
neopharynx. We usually start the patient on oral liquids after 12 to 14 days.
● Look out for aspiration, especially checking the posterior tracheal wall for any wetness, which
suggests salivary aspiration. Usually this settles down once the patient is swallowing normally.
● Voicing is initiated after three weeks. The stoma is occluded and the patient is instructed to cough.
This forcible blast of air is required to clear the retained secretions and crusting. The patient is then
asked to phonate single words usually numbers.
● He is then counselled for speech progressing from single words to sentences, step by step building
lung power and developing control over their breathing.
CONCLUSION
Near-total laryngectomy is an oncologically sound procedure which creates a biological shunt which is
dynamic and maintenance free. Once functional, it gives the patient an almost natural voice without
problems of prosthetic shunt which are recurring cost and doctor dependence.
References:
[Link]
Near-total Laryngectomy;1 Prathamesh S Pai, 2 Sultan A Pradhan;Published in: An International Journal of
Otorhinolaryngology Clinics. 2011 August